Janet: When you get up this morning, did you shower, brush your teeth, do your hair, pack lunches, get everybody out the door on time to catch school buses, commuter buses or get in the car and go to work? Guess what? You were using a workflow. Today on Get Social Health I’m talking with Chuck Webster, he is the Workflow King. I think you’re going to enjoy this conversation on Get Social Health.

Intro Voice Over: Welcome to Get Social Health, a conversation about social media and how it’s being used to help hospitals, social practices, healthcare practitioners and patients connect and engage via social media. Get Social Health brings you conversations with professionals actively working in the field and provides real life examples of healthcare social media in action. Here is your host, Janet Kennedy.

Janet: Welcome to Get Social Health. Today on my podcast I’m going to get to be the 101 level student because I’ve got Chuck Webster with me. He’s known as @wareFLO in Twitter and in social media. We’re going to talk about workflow process. Keep in mind that I’m representing the marketing social media side of the house and I’m not heavily involved in an IT operations process. For those of you in the same boat as me, we’re going to really dig in and do some 101, however, if you’re on a more technical side of the house you can just laugh along with us. Chuck, welcome to Get Social Health.

Chuck: I’m so excited that we finally pulled the trigger on this. I think we’ve been talking about doing it for I think about a year.

Janet: It’s been a long time. I know we even scheduled a few times and both had emergencies come up. I don’t talk about technical very often, I have to admit because I’m a little uncomfortable, it’s something I don’t know what I’m talking about but since I set the groundwork that I get to ask all the dumb questions, we can move ahead with this.

Chuck: Okay.

Janet: All right. You are known as @wareFLO and of course it’s not @workFlow, did somebody already have that Twitter handle?

Chuck: No, actually someone did but maybe I would have grabbed it but wareFLO no W at the end is what the linguist call a portamento which is a combination of two different phrases and so ware is software and flo is workflow so software workflow and then I capitalized the F-L-O at the end just to be a little distinctive.

Janet: I see, I would have said it means so where is this going but in many ways that actually works too.

Chuck: No, no, no. Actually, also there’s wearFLO as in you wear something. I gave a keynote to the Society for Health Systems in a conference last year and the topic was wearable workflows so that works too.

Janet: Very cool. We may get to that. Let’s go back a little bit and tell folks who you are who may not know who you are. I see an MD after your name but that’s only two of about a dozen letters so can you give me a little bit of background of why you’re a perennial student? What have you gotten your degrees in?

Chuck: My mother says I’m killing myself by degree. I started out in engineering and I became interested in healthcare cost, savings, efficiency sorts of things. I ended up with a BSA, a Bachelor of Science in Accountancy at University of Illinois which by the way is the number one school over here. Because I started in engineering I had taken all the chemistry, physics and biology necessary to apply to medical school. I was going to get a PhD in Health Systems Engineering and my advisor when she found out that I had taken courses necessary for medical school said, “You know, you really ought to go to medical school because the MD is the PhD of healthcare.”

She would do these incredible studies of where to put the air ambulances in the state of Illinois and the doctors would just kind of ignore her because she was a PhD which they are an ivory tower sort of person and they don’t even know what the PhD is. It’s not a real doctor, the MD is the real doctor and all of that. I have two other Master’s. One is in Industrial Engineering so industrial engineering is all about usability and workflow. I spent a year in aviation human factors helping to design jet cockpits. Then I spent a year in hospital workflow, actually working with the folks and the student Hospital of University of Illinois, did computer simulations of patient flow.

I ended up getting also along the way a Master’s in Artificial Intelligence, that has to do with things being smart enough to understand what needs to be done and help the users. I have one more degree which is an ABD, all but dissertation which means I did all the courses didn’t finish the thesis. That is in Computational Linguistics which is natural language processing. I did that or didn’t do that at Carnegie Mellon University of Pittsburgh.

Janet: Golly gee, Chuck. Through all that, how do you contribute to society, truly?

Chuck: If you intersect the domains that is accountancy is about cost, industrial engineering is about workflow, artificial intelligence is about knowledge representation, and medicine, at the intersection is workflow technology because you’re representing cost and models of tasks and you have engines that are doing things efficiently. Pretty much the stuff that I just go on and on and on and on about right now if people think of me as Dr. Workflow or the Workflow Bearer or the King of all Workflow in Healthcare. Some novelist say that the plots are really just driven by characters. If you have a set of characters, there are certain way you throw them together in an environment and then the plot just happens. It’s like the stuff that I’m interested in which is healthcare workflow and workflow technology is very much driven by the degrees I got decades ago.

Janet: You’re really a living Venn Diagram?

Chuck: I am, in fact, I want to give a slide sometimes a presentation. You know, you have that slide about yourself? It literally is a Venn Diagram. I have four circles and they are all intersected and they are labeled cost, workflow, representation and medicine. At the intersection is workflow technology or what’s called Business Process Management today.

Janet: I really want to talk about BPM or Business Process Management in a minute but let’s go back a little bit to your early career where you’ve finished all these you’re schooling and now you’re going to start to apply it. Were you always focused in the health care space?

Chuck: Yes but I’ve kind of systematically kept, if you think of me as an octopus with a bunch of legs so I keep the other seven legs in other areas. I’m a bit of a dilatant in a sense that I delve into other industries so I spent a year in aviation human factors so I follow what’s happening in the aviation industry. My wife is a well-known consultant in customer service and leadership in the hospitality industry. I do this systematically because there’s all kinds of stuff you can borrow, safety from aviation, high touch experience from hospitality. I’m always borrowing from other industries.

Janet: It’s only a matter of time before we have the Disney Doctor course. It’s coming in time.

Chuck: You know what, I think it already exist.

Janet: I’m wondering about when you first started talking about workflow in healthcare. Obviously, you need to be speaking to senior C-level executives at hospital systems. Did they get it? Was it an alien concept? Is this something that they were very comfortable grasping because this is kind of a technical world and not super soft skill? Was this something you have to evangelize about what exactly is workflow and why is it important?

Chuck: Basically, education and evangelizing and marketing all work together because I was chief medical informatics officer for an electronic health record vendor for over a decade, a small one. Not so coincidentally I mean I sought them out it made sense. They were an electronic health record built on workflow management technology, workflow engine, users could design their own workflows and then the engine would interpret them. People complain about workflow all the time. It doesn’t fit what they want to do well then in this case you can change the software’s workflow to fit the human workflow. However, in selling that to the rest of the world you had to educate people. A lot of people think workflow is boring. Maybe it is but it still, all purposeful human activity involve some form of workflow which is a sequence of actions consuming resources achieving goals.

It’s a little dry and it’s a little foreign because health IT is really all about data not about workflow which is part of the problem, in my opinion. There’s a lot of both education and in treaties trying to tantalize people to get them interested in workflow and then once you got them interested, got their attention kind of the education component and then finally I’m really not all about workflow. I’m really about workflow technology which of course as soon as you start talking about technology and then people’s life start to glaze. It has been an upward battle for a couple of decades but I see lots of interesting flowers blooming in the spring, so to speak. This moment, particularly over the last three to four years in health IT regarding better workflow, better software that supports human workflow better.

Janet: I’m picturing in my mind Leonardo da Vinci and his mind mapping. Am I on the right track? Is that really what we’re talking about is here’s all these things that happen, now, how do they come together?

Chuck: Okay. Up till now where in I talk about all these different domains and how they connect, yes, but I think you put your finger on it. You know how when you draw a mind map, you label a concept and then you put down another concept and you draw an arrow between them and you use this for brainstorming and for people to communicate. Imagine that your mind map is of a workflow, that is you’re actually drawing the workflow. The workflow has three steps and each step has certain qualities or processes or resources or goals and you draw little arrows off to those things and when you get done you’ve got this 12 or 13 balloons with a dozen or 18 lines and some labels but then you push a button and it turns into an actual application.

Something a computer, this was created by a non-programmer and it’s at the level of the domain so you can have a doctor and say, “Okay, describe your workflow.” The doctor describes their workflow and then you’re going to have the specialized software called a workflow engine that actually goes and mechanically looks at their drawing and says, “Okay, this is the step I’m on. This is the screen I need to show this person. Now that step has been completed. Now, this is the screen I need to show that person,” I’m trying to pivot here from this idea of mind map is a graphical representation of something to the idea of a graphical representation of workflow which is essentially what workflow technology is.

Janet: Right, I have a picture in my head and I wonder if this is the correct vision here. You have a meeting and people are walking through, “I do this then I do this and I do this and I do this.” It all goes into this really smart machine. Now, is this machine just translating it into a capturable process something software driven or is it able to actually use some of your artificial intelligence to say, “Wait a minute, you’re out of step here. You’re in a wrong sync here and wouldn’t it be better to have step four as step three?”

Chuck: Yes, absolutely. You’re seeing workflow technology and now academics call this process-aware technology and when they say aware they don’t mean it gets conscious. They just mean that it can introspect, it has a representation of a process and they can reason about it. A lot of these systems have got machine learning that can watch the behavior of the system and spot the bottlenecks or spot the rework. If some step happens over and over again well then maybe you need to change the workflow so it doesn’t happen over and over again. In the natural language processing world there are technologies out there which you basically feed the software a bunch of natural language.

Basically, the corporate documentation, it’s full of organizational charts and lots of workflow descriptions and you feed them into the system and it actually constructs a workflow diagram that you can then critique so you can either take one that is created by hand compare it to the evidence and then improve it. In some cases it can perhaps even create a draft version to show that humans can look at it and critique it. Ultimately, it’s the proof is in the pudding, that is when the workflow engine runs against a representation of workflow it either creates a nice experience that is efficient and effective or if it isn’t, if there are points that are raw or rub or sharp and you can go in and people can go back and iteratively improve it. It really fits into what the health IT people call agile development except it’s agile development at the level of workflow.

Janet: Have you ever found in working with groups where you might have a number of people part of this process who don’t normally interact with each other that you come out with a workflow that is totally contrary or so different from the way they had envisioned it because they didn’t realize that this piece over here needed that piece or that maybe here’s like, “Yeah, we do this everyday,” it turns out if they did it the way they said they did it it’s a three week process?

Chuck: All the time. I mean, even before workflow technology came along. If you got a bunch of people together and by hand you got them all in the room together and I did this at a community hospital in Pittsburgh where we cover the walls of a board room with the white butcher paper and we used sharpies and we brought people in from all over the hospital and so the workflow from this department would lead to the workflow in this department, would lead to the workflow in this department and we try to create a giant workflow diagram of all the processes, all the workflows in the hospital. People would say, “That’s not the way it is,” and someone else would say, “No, it is the way it is.” Then so there’s a way of getting people on the same page so literally in this case, sheet.

Now, that you can take data out of electronic health records in other systems when someone clicks on a button, they did something at a particular time. Now we have evidence based workflow. You can show people, with this called process mining, process mining is like data mining except it’s applied to all of that time stamp data that’s in the electronic health record and other health IT systems. You can generate a process map, you show that to people and they’ll say, “That’s not what I do.” You say, “Let’s drill down here, you’re on this screen and you click this button on this date. You didn’t do that?” They’ll look at it and they’ll say, “Yeah, I did do that. I guess you’re right, I forgot to tell you about that.”

Janet: Who could remember all the details number one? Give me an example of how this workflow might work. Is this something you’d use to say, “Hey, why are lab results taking so long?”

Chuck: Yes, absolutely. Imagine you’ve got this loop where you’re writing something, you’re clicking on something and then some time passes and then something arise. In between, a bunch of stuff has to happen like specimens have to be collected and then within the laboratory information system there are multiple steps of workflow and levels of quality assurance and so forth and all of that in our current workflow oblivious health IT systems it’s opaque. It’s a black box so you push the button, you don’t know what happens and then finally get it. If it takes too long, wouldn’t it be great if you had a process map that showed you every little step of the journey that your lab order went through and you can then say, “Wait a minute, why did it sit here for a week?” Someone can go, sometimes it’s a red face they go, “I was on vacation.” Then you can change the workflow so it doesn’t happen again.

Janet: Cover that from a patient’s perspective, “Why do I care about workflow? How would it apply to me?”

Chuck: There’s two interesting angles there. The first is I’ve seen studies that have shown that for a chronic condition and an operation related to it. There may be 20, 30 touch points between health system and individual and you’re talking maybe over a dozen various clinicians and if these people are asking for the same information over and over again or the right hand doesn’t know what the left hand is doing and the lack of coordination is obvious then you’re going to lose confidence in the system. That’s the system behind the smiles. When the hospitality industry you walk in and the room is ready and you go right in but there’s all the stuff, there’s all those back end stuff that had to happen and that front end where you got the staff and they are smiling and they are nice and they are saying, “Yes, ma’am, here you go. Here’s your key.”

They can’t do that, they are not free to live their organization ideals unless they can just count on all the workflows in the systems many of which are IT systems work perfectly. You don’t know and you don’t want to know how all the magical stuff happens but someone has to figure that out and make sure that it works perfect or well enough. The other aspect of that is that patients and humans even if they are not in the hospital they have work, you and I have personal workflows. We have workflows that we use to make breakfast and to multitask between while we’re talking to someone or we know exactly how long something is going to take to wash or to cook.

These, it could be called life flows. Okay? These life flows are interacting with for example, notification systems. In our smart phone, in our smart watches, our fridges, our appliances and all of them are networked together and they all need to be coordinated too. Now, if you’re at home where you’ve got all kinds of healthcare related monitoring, that internet of things IOT level, you also need these life flows to be coordinated. I’ll give you an example. A notification, you got a ding, you look at your smart phone while if you’ve got three smart phones sometimes you hear three dings you’ve got your watch. You need a system that says, “Wait a minute, all we need to do is deliver one notification. We just need to make sure that is delivered in the right time and in the right manner,” that’s kind of a classic workflow management system workflow engine responsibility.

Janet: Wait, wait, can you tell me how to do that because it’s killing me?

Chuck: No, no, it’s funny. Yeah, I can’t remember who it was, I might have been a [Jur Piano 00:19:37] and all of a sudden I heard like about 12 dings on his side. Yeah, smart notifications are definitely coming and that’s going to be … Also for example, patient instructions and reminders to take their medication and so forth. You don’t want seven different identical reminders but you might not be wearing your watch and so the system, you’d say, “Well, we’re going to send it to the watch. Wait a minute, they didn’t respond. Now we’re going to escalate it.”

All those rules that you use when you’re trying to deliver a message and then you don’t receive evidence that the task was accomplished and then it gets escalated to the next level. Then it might even be escalated to a human. You see, if someone doesn’t like push the button on their smart pill dispenser saying, “Yes, I consumed the pill,” you may get a knock on the door from your mom, someone who’s agreed to participate in this semi-automated life flow. I know that sounds like science fiction but there are start ups and folks working on exactly the scenario that I’m talking about.

Janet: Especially from the stand point of our desire to be living at home as long as possible but that does mean that there needs to be some kind of monitoring and some kind of awareness particularly as we have so many generations who are not living near each other.

Chuck: I originally wanted to become an anthropologist and I didn’t do it basically because the job prospects for anthropologist apparently are not so high but anthropology is about workflow in culture and in human groups. For example, when I define workflow to be a series of steps consuming resources achieving goals, a series of steps can be a ritual or a series of steps in some coordinated activity. A field anthropologist conducting ethnography is sitting there writing notes and he’s basically writing down workflow notation of anthropological sort and consuming resources. It’s consuming animal carcasses, it’s consuming the time of folks. It’s achieving goals.

Those goals may be sustenance, safety, protection from the elephants, group cohesion and so anthropologist are very much like industrial engineers in the sense that if they go in and they document these workflows, although the languages and the rotations are different. You can easily imagine these applied anthropologist working together with the workflow where health IT start ups of the world to create the kind of digital support at home so that just fit seamlessly into the living life flows of those folks who are being supported at home.

Janet: That’s a world we all need to have because as we age and the boomer start to outnumber the young people who are able to care for them, we’re going to need more digital tools to keep us mobile, on time, taking our right meds and indeed giving us reminders or giving us connection to other people.

Chuck: I’ll say this, I frequently get into sometimes a rather strong debates and people keep talking about, “I want my data.” Guess what? I don’t want my data. I want my workflow. I want reminders. I want nudges. I want to know what to do next. The only reason people really want their data is because they need to be their own workflow systems. I have to get the data from you so I can take it over to you. What if I didn’t have to get the data from you to take it over to you so that you could then make the decision to remind me to take the pill I need to take? That’s really workflow. What I think people really want is they want control over these life flows and workflows around them that are working on their behalf although even though they are maybe irritating and nudging and nagging unless it’s less about, “I want to be able to download all my files in electronic format.”

Janet: Honestly, I don’t want my data because I don’t know what I’d be looking at.

Chuck: Yeah, right.

Janet: It doesn’t really help me. Let me ask you a question about who is this person in a healthcare environment? Obviously, you do consulting work and you come in and you help organizations with specific problems and situations but you’re not there all the time. Is there a position in hospitals and healthcare systems that you would be if you’re there? What is it called? Because nobody’s going to go get five degrees in order to become you.

Chuck: Every year in US [inaudible 00:24:21] reports or whatever you’ll see it will show you a list of ten job occupation that won’t exist in five, ten years. Talking about C-level individuals as being bellwethers. You know, the chief transformation officer, chief innovation officer, chief engagement officer. I’m starting to see chief process officer. You can just Google chief process officer and it will tell you salaries. The thing is that people talk about these silos, silos of data. I say, don’t think about it in terms of silos of data. Think about it as silos of workflow because what you’re trying to do is link up workflows between these silos so that they work together seamlessly.

Yes, you’re right, someone that shouldn’t have to go and get five or six degrees but I was an assistant professor and I designed the first undergraduate degree in medical informatics back in the 90’s, that’s designing a curriculum and as you know because you do curriculum design that’s part of your social media outreach and education is a kind of an exciting and intellectual thing because you got to look ahead into the future, you got to predict where things are going, you got to say, “Okay, I’m going to take a little bit of this, a little bit of this. I’m going to put it together in a certification and a degree or whatever.”

Yes, I think that you’re going to see some of this folks are industrial engineers, some of them are nurses who go and get a certification in IT but kind of fall in with the right group in terms of, I don’t really want to be a data analyst but I don’t mind being a workflow analyst because it’s closer to touching the user whether that user is a clinician or an admin or perhaps even a patient.

Janet: Interesting. I do think that’s very exciting because there are a lot of healthcare providers who have unique skills I think of all the physicians that I’ve interviewed who are really technology nuts. They [laddered 00:26:29] in social media because they really like the engagement, they like the communication method, they like being on a cutting edge and I think once you’ve been experienced in a large system it would be very sad to retire to the golf course because even if you’re maybe too tired to keep up with the very heavy workload of a physician or a nurse, this is such a great application for your knowledge base.

Chuck: Yeah, and the great thing about you don’t have to be a computer scientist to be able to map workflows. If you want to program you got to learn C Sharp or Java and then take database course and operating system course but you have to do all those things in order to create an application. In the workflow technology world it doesn’t matter where they come from, what’s most important is that they understand the domain and that means that they understand their workflows and the workflows of the folks that they are trying to help. You think about business analyst, you think of this as clinical workflow analyst. Then they don’t have to be a Java programmer because these systems are what’s called less code or low code or code less.

You can basically create an application without having to write all of that text down and compile it and fight through. There’s an opportunity to bring the people who really understand the domain workflows together with the platforms that will allow them to create their own applications. They call these citizen developers. It’s happening in other industries. A citizen developer, you think of a citizen soldier. Citizen soldier is someone who is a volunteer or in some countries you have to serve a couple of years but then you have to keep the rifle under your bed like they do in Switzerland, locked up by the way. Citizen soldiers, these are folks that are doing something important for the rest of everybody else because they can and because they should.

I think we’re going to see something like that in healthcare software. We’re going to see citizen developers. I mean, it’s already happening. In fact, it happened for decades and that is there are companies out there that some doctor in some area got together with his brother or sister-in-law who’s a programmer or vice versa and then they built an application that’s now multi billion dollar company. Today, with the technology that can happen much more quickly and less expensively.

Janet: There was actually an article that came out if not this week then maybe last week but it basically talked about innovation needs to be coming from the medical side of the fence and not from the innovative entrepreneurial side of the fence. Many schools have thought on that but the bottom line to this article was it’s really physicians and nurses who know what problems need to be solved, they need the digital health partners to make that come to pass as opposed to the 6,000th app to manage your calorie count.

Chuck: The great thing about workflow technology is you’ll often hear folks saying or bemoaning that we don’t have clinicians more involved in the design of software before it is implemented or deployed. Guess what? With workflow technology software you can design it after it’s deployed. You see, because you can put that workflow in there that if you can draw approximately correct workflow you can put it in and it can be changed on the run. You can swap two steps by just dragging and dropping. You don’t have to go all the way back to the health IT vendor. Yes, it’s important that we get clinicians involved in the design of workflow both before and after. It’s that after that is so important because that’s when you actually see whether it works or not, that’s when you say, “Oh my gosh we forgot this, we got to add this step.”

Janet: Let me ask you a question about an actual workflow process. You’ve gone in and you’ve mapped out I don’t know, OR prep or something like that. How often should workflow be reevaluated?

Chuck: Gosh, that’s going to be case by case basis. It depends on how close you … Okay, when you draw out this workflow and then you double click on all the icons and you set some properties, these are the business rules that are about escalation or when this step is executed I want an SMS sent to this phone. If you do a really, really good job upfront then it’s like day one, wow this really works great and then just a couple of little tweaks. On the other hand, if you get something out there that is only halfway thought through and when I say only halfway thought through, a lot of the workflows in healthcare are so complicated and maybe so almost illogical to some people that you really can’t do better than half thought through.

It’s in those situations that you’re probably it’s going to be like an exponential function but I mean, just going to start up high and then it’s going to drop down and get less and less. Now, whether that happens over a week or a month but I will tell you that workflow technology software, one of the things that it does really, really well is it avoids these multi year implementations that you hear about. The electronic health record it took them two years to implement the electronic health record and that’s because the cost of changing the software after it’s been deployed is so high and it’s so laborious that it slows you down and it’s so expensive. That’s when you hear about these 100 million dollar situation. Some which have sunk hospitals or CIO or even CEO careers. With workflow technology you can change the workflows after you’ve implemented it.

Janet: Now, without naming names, do you find that these big companies are actually open to outside consultants or client feedback on what’s not working or are they so wrapped up in their own workflow process that it is like, I don’t know, stopping a speeding train.

Chuck: They’ve maybe getting better but like a couple of years ago I did a focus group, two day focus group at Chime down in Scottsdale with 40 CIOs from UCLA and all across the US. Unfortunately, part of the reaction was, “You know, we really love this workflow technology stuff. We get all the logic that you and I had talked about. The problem is is that meaningful use have sucked all of the air out of the room. We’re so focused on getting that subsidy. We don’t have any excess resources or attention to try anything innovative.” Now, I think this meaningful use becomes a bit longer in the tooth, I think we’re going to see stuff improved, the problem is is that meaningful use is being relabeled and now you got macro and it’s being resold. The jury is out on that.

I think ultimately in every other industry applications have followed an evolutionary pathway. Back in the 60’s and 70’s, all the software was all mixed together. You have two applications and the data is separate. I mean, that’s the classic situation where you have to reenter the data then they pull the data out and they shared it in the database. Then the next evolution they pulled the user interface out so when you click on a button, the application isn’t responsive but the button is the operating system, Windows or Mac OS and the application just says, “Make a button and find out what the user wants.”

Now, what’s happening is the workflow is being taken out of these applications. You can have a bunch of different applications and the workflow is all represented in a single place and the workflow engine is running against it. That evolution that I’ve just described has happened in every other industry. Healthcare, the health IT is 10 to 20 years behind other industries. It is inevitable. The only question is how fast. One of my roles, I have self-anointed roles is to try to accelerate that evolution toward these process aware systems because the workflow obliviousness of a health IT that we’ve implemented, this sounds a bit floored to say but maybe killing us.

Janet: One of the things you mentioned to me in our pre-interview conversation was trying to recruit some of the top minds and vendors in the workflow tech area to come in to healthcare. What’s the problem? Is there no welcome mat out there or they see healthcare as too long of play?

Chuck: A little of both. I go to three or four or five business process management conferences a year and they are looking at the multi trillion dollar healthcare industry in which people estimate a third or a half is wasted in administrative stuff and they say that’s ideal for automating it with workflow technology. On the other hand, healthcare is a foreign country. It’s like when I went to medical school, all these new words and acronyms it’s all very confusing and it’s hard to prioritize. Part of the problem is is that they kind of don’t know how the product ties. I helped them with that. The other thing is that often someone will find them, someone from healthcare who’s like at wits end will go outside of healthcare, they’ll bring in this workflow technology vendor sometimes they are called adapt a case management dynamic, case management business process management and they’ll have a success, a one off.

Then the question was how do we pivot from that, we’ve got a foot in this healthcare organization’s door and then it will often be in human resources or in the trans industry, in a payer side. Basically, because those are areas of healthcare that are most similar to other industry so you’re going to see the earlier successful importation of workflow technology in those areas but what happens is CIO gets a look or there are a lot of CIOs that are coming from other industries and they already know about workflow technology. I’ve seen job ads for both CEO and CIO in which the job said, literally this is in the job ad, literally says not only is no healthcare experience required, it is disallowed. “Do not apply if you are coming from healthcare. We want people from the airline industry, the hospitality industry who are using this kind of technology.”

Part of the reason that I’m on social media is that when I worked for a health IT vendor the sales cycle is very long. I mean, nine months or more where you got to wine and dine and get through the right people and then maybe you get shut down right at the end. You’re investing a lot of time in one off situations. I’ve got almost 10,000 followers like a lot of CIOs, CMIOs and so what I’m doing is trying to put a lot of great educational content out there about workflow technology to 10,000 because I don’t know who is going to bite. It’s like fishing. You got to go some place where there’s a lot of fish. I spent a lot of my time creating content getting those people listening to me so I kind of ran on on that but you get my point.

Janet: You also have written recently on this and are going to be in a book. What’s that?

Chuck: In the business process management industry I believe the publisher is a future strategist. They write a line of business process management books and with the workflow management coalition there’s a yearly award. I’ve been a judge for the business process management and a case management awards for excellence. What they do is they just basically send me all the healthcare stuff which I’m happy to do. I think I’ve done it for about five years. I’ve had chapters appear in three or four of their books on knowledge workers and business process management and they’ll be like a talk in the healthcare chapter and that’s mine.

Now, they are putting out together a collection of chapters and chapters that are based on successful applications for these awards for excellence in business process management, case management. One of the chapters is mine which it appeared in the previous edition but I’m also writing the foreword and I’m delighted to do that because obviously I say nice things about business process management and healthcare but I also get to talk about the genesis of my interest which we’ve already somewhat covered.

Janet: Awesome. Chuck, I am so enlightened and for a guy with lots of letters after your name this was an incredibly friendly down to earth and understandable conversation.

Chuck: Thank you for saying that. By the way, Janet, I’ve enjoyed all of our interactions on Blab for example and hoped that we will have more wonderful social interactions. It doesn’t even have to be about workflow, it can just be about healthcare in general.

Janet: Awesome. Okay, I am going to ask quickly you tried out a new platform yesterday called Fire Talk, how it go?

Chuck: It went very well. I was very impressed. It does about 85% of what Blab did and it does a couple of other things that Blab doesn’t do, didn’t do. I encourage people. On Fire Talk I am firetalk.com/wareFLO and that’s seven letters no W at the end. W-A-R-E-F-L-O. Firetalk.com. What you do is you use your Twitter account or I think also Google or Facebook, you register with them, you have a profile and then you create a channel. That channel is always on. Basically, I put a bunch of YouTubes on there and the YouTube just run in a circle so anytime anybody goes there they can see and a lot of these YouTube or Blabs that I did that I downloaded and put over on YouTube but now I can bring them back in.

Then what happens is you basically interrupt that channel with live video of where you have two or three or four people just like on Blab and there’s an audience and comments and it’s integrated with Twitter and social media and you can schedule something. Now, the thing that’s interesting about Fire Talk, part of the reason Blab went away is it really didn’t have a good monetization strategy. Fire Talk allows you to have free shows but also it allows you to sell tickets so you’re probably going to see musicians and so forth take advantage of that and I’m hoping the fact that they do have a monetization strategy will keep them around because I really like them.

Janet: That’s great. I promise I will be there at the next one or I’ll be hosting one myself soon. Of course you can find me just look for Get Social Health and that’s my Twitter or my website, my podcast and now my Fire Talk site.

Chuck: Yay.

Janet: Chuck, thanks so much for being here. I look forward to our future conversations and you are now my go to workflow man.

Chuck: Viva la workflow.

Janet: All right. Thanks so much for being here, Chuck. I look forward to talking again soon.

I tweet a lot about the important difference between price transparency and cost transparency. (I was a premed-accounting major…) A couple years ago lots of folks talked of cost transparency, when, in my opinion, they really meant price transparency. I kept corrected people. I eventually gave up. Though I should note that most of the time I see price transparency correctly used now. But it got me thinking about the relation among price, cost, quality, and value on one hand, and my favorite subjects, workflow and process.

Usually one starts with an outline. However, in this case, there is diagram, which I explain, in detail, later, which shows how everything fits together: price, cost, quality, value, workflow, and process.

Here is some background. What do people usually mean by workflow and process? Systems thinking is all the rage in healthcare. What is the relation among systems, workflows, and processes, at least to this systems engineer…?

Productivity 101. Economists usually speak of labor productivity, but it is a more general notion that that. It is simply outputs divided by inputs. To double productivity means to double the output due to the same level of input, or to maintain the same level of output while cutting input in half,… and so on. I’m sure you get the basic idea. It is similar, by analogy, to amplification in electronic circuitry. Your radio takes a very week radio signal and turns it into a very loud audio signal. Highly productive systems, organizations, economies, workers, can do a lot with only a little.

The above and below slides seem redundant to each other. Need to consolidate.

This is perhaps the meatiest slide of the slide deck, and therefor requiring the most explanation.

The basic point of this slide was simply to translate a general systems engineering idea into a healthcare systems engineering idea. Price and cost are inputs to a “service line”, a bundle of workflows and processes necessary to provide a specific healthcare product or service. Think, the price, versus the cost, of a hospital procedure, such as an appendectomy. The price is set by market and/or regulatory forces. The cost is the expense to the hospital. This expense depends on the costs to the hospital of labor, consumables, durables, rent, etc. These costs also depend on prices in markets, but from the point of view to THIS organizations, they are costs. (Just as the prices the hospital charges are costs to patient and/or payers.) I know it is confusing. They are the same. And they are NOT the same. From the point of view of the healthcare organizations, the difference between price and cost is retained by the organization as profit (in the for-profit instance) or surplus (in the non-profit instance).

Firms use internal cost information to set prices. In general, they charge what a market will bear, unless constrained by regulations. However, if they cannot charge at least as much as their known true costs, in the long run, they will go out of business, leave the market, drop that service line, or figure out how to perform the workflows more inexpensively.

Quality is the degree to which a workflow and/or process fits the purpose of the workflow, that is, satisfy the goals of the workflow. Quality exists irrespective of price. However, value is a relationship between quality and price. In principle, if you know price and you know quality, then you know value, so transparency with respect the price and quality should be sufficient for transparency with respect to value. (I’m sure it’s more complicated… but I’ve got to make some simplifying assumptions somewhere, otherwise this whole hot mess is simply too complicated to think about at all!)

Sooo…. what’s missing from discussion of healthcare price, cost, quality, and value transparency? Workflow transparency, also known as process transparency.

Umm, already covered this. Reorder or consolidate.

Reorder or consolidate.

Reorder or consolidate.

Reorder or consolidate.

If you are providing me a product or services, why should I care how you do it? As long as the price and quality are right, I should like to view you as a “black box”, right? The problem is that healthcare workflows are so complicated, and they meander over and through so many healthcare, and health IT, systems, it’s getting harder and hard to figure out where to draw the boundaries between black boxes.

In fact, a big, big trend in business today is to take your back-office and enterprise workflows and processes and make them into front-office self-serve workflows and processes. Millennials don’t want to deal with you face-to-face, by phone, or through email. Just give them an app, so they can check the status of something, cancel something, or to modify some workflow or process, in real-time, to their satisfaction and convenience.

The only technology that can manage these, previously blackbox-enclosed, workflows is workflow technology. It models the workflows (sequences of smaller black boxes, called activities or tasks). It executes the workflows. It makes the workflows available, at scale, to folks outside the black box. They can make blackboxes transparent, at least regarding workflow, but that is actually a really big deal.

I need to work on this slide some more. The basic thing I’m trying to convey is that the route to making a service line, and entire bundle of workflows and processes, transparent in operation, is to break up the blackbox into smaller, interacting black boxes. In workflow management and business process management parlance, these are activities, tasks, steps, etc. They have inputs and outputs to each other. They cause things to happen to a patient, and they receive actions from a patient. They drive costs and provide information for the firm. What keeps all the ducks in a row? Workflow engines, which are single most defining architectural feature of workflow management and business process management systems.

Above is a typical list of features and advantages of process transparency. In a 2015 five-part series published in Healthcare IT News I wrote at length about task and workflow interoperability. I was writing about healthcare B2B task and workflow interoperability, not C2B (customer to business) or B2C (business to customer) interoperability/visibility/transparency. However the general principles hold for all three combinations. (Though one does wonder, what might C2C interoperability/visibility/transparency mean for healthcare…. for perhaps patient family members and bird-of-a-feather disease-centered support communities and support groups.)

This is what wrote about task visibility (transparency)…

This is what I wrote about workflow visibility (transparency)…

OK! We covered price, cost, quality, and value transparency, and then workflow or process transparency. What is the relation between the former and the later? In the long run, not only can we not optimize the former without the latter, in many cases, we cannot even measure important aspects of the former without the latter. A majority of healthcare costs come from expensive human labor. The only practical, scalable way to measure this costs is through some form of activity-based cost accounting. These activities are the same activities that workflow management systems and business process management systems model, execute, measure, and monitor.

In my 2015 series I noted two categories of people and organizations laying foundations and pursuing workflow interoperability in healthcare: health IT companies and organizations, and companies from the workflow management/business process management industry. Since then two more groups joined the fray. On one hand we have the citizen developers and citizen integrators, who are creating new health IT systems and workflows. On the other hand, we have standards organizations, such as HL7 and OMG (Object Management Group), both of which are beginning to address standards and technology necessary for task and workflow interoperability. (By the way, I just came back from a workshop on this subject, the Healthcare Business Process Management Notation Workshop, in San Diego.)

Yes, it will certainly be interesting see how all these task/workflow/process transparency/interoperability stakeholders get along with each other!

Prices and costs are different concepts. Therefore price transparency and cost transparency are different concepts. Prices, and therefore price transparency, are influenced by markets and regulations. Costs are determined by resource expenses (people, consumables, rents) and technology (methods for transforming resource inputs into outputs). Competition pushes prices toward costs (which is why cost transparency is necessary for long run price transparency). Quality is how well workflows and processes fulfill their needed intended purposes. If we know price and quality, then we know value. And some form of workflow technology is necessary to monitors all the activities that make up the workflow and processes that transform inputs into outputs.

This post consolidates a large number of papers and examples of using Business Process Model and Notation (BPMN) in healthcare that I reviewed during preparation for the workshop. I’ve been advocating workflow technology in healthcare for over two decades (My Foreword and Chapter in Business Process Management in Healthcare, Second Edition). In fact, I may have been the first to discuss, at length, Business Process Management (BPM) based health IT systems, including Electronic Health Records (2004, EHR Workflow Management Systems: Essentials, History, Healthcare). BPMN is not the only workflow notation relevant to process-aware health IT systems. Nor do all workflow management systems rely on a formal notation at all. However, as awareness, understanding, and use of BPMN spreads in healthcare, workflow management system and business process management technology will also surely spread, which is a good thing.

Here is some information about the Healthcare Business Process Modeling Workshop.

“Experts from the medical field and business modeling will discuss how OMG’s business process modeling standard can streamline the portability of clinical processes and workflows that govern how protocols are followed and care is delivered in healthcare organizations. For example, the agenda includes:

The Usage of BPMN™ for Obamacare

Using BPMN to Operationalize Clinical Knowledge

Integrating Clinical Information Modeling with BPMN

Modeling the Cognitive Side of Care Processes. Case Study: The Treatment of Atrial Fibrillation

Modeling Cancer Treatment Processes in BPMN and HL7 FHIR®”

“Within the health segment today, provider organizations each have their clinical processes and workflows that govern how protocols are followed and care is delivered. One of the operational challenges in becoming a “learning” organization lies in the ability to adapt and evolve those processes to embrace emerging best clinical practice, and to perform continuous improvement based upon care delivery and care outcomes within your own institution. Further, the professional societies and colleges continue to evolve and mature their guidelines, and staying current with those means incorporating that medical knowledge into your care pathways.

In a landscape where clinical knowledge and medical workflows are often either embedded in electronic health record (EHR) systems, or manually configured at an institution or site level, accommodating these changes can be timely, difficult, or near impossible to realize. Moreover, these rules are often expressed in “geek speak” and not in a language that can be owned and managed by the clinical community.

Business Process Modeling Notation (BPMN) is a non-healthcare-specific representation of business processes and workflows that has both broad adoption and a robust set of support tools. BPMN has enabled other vertical sectors to model these needs en route to creating reusable knowledge artifacts that could be shared and in fact interoperate across systems and organizations. Recent work in the industry have uncovered gaps in how BPMN should integrate with the healthcare workforce to support truly portable, patient centered processes. To put it in a different light, BPMN standards have helped define the baseline for What should get accomplished in any given health care process. The implementation of BPMN in healthcare is increasingly challenged by Who should be responsible for any given task.

This workshop is geared toward exploring the specific and unique needs of the clinical health landscape, investigating BPMN and the extended set of BPMN enhancement standards to determine the viability, coverage, and gaps when considering this approach for solving the healthcare challenges described above. Of particular interest is an exploration on how best to integrate BPMN with the healthcare workforce.”

Enjoy my research review preparing for the Healthcare BPMN Workshop! (By the way, there are lots of cool looking healthcare BPMN diagram examples!)

Consider engaging in a series of activities, say starting your car and driving to work. If at any point — trying open the door, trying to start your car, trying to put it in gear, trying to push the accelerator, trying to turn the wheel, trying to push the brake, and so on — what you do fails to achieve the result you desire, how to you feel? Powerless.

On the other hand, imagine you are captain of a starship. Your systems and people are incredible. Their processes and workflows are automatic, transparent, flexible, and always improving…. Every command you utter triggers incredibly sophisticated workflows that always achieve exactly what you wish. When you say, “Make it so!”, how do you feel? Powerful.

Powerfulness and powerlessness, in this workflow sense, are closely tied to a related psychological concept, “flow”, described in Flow: The Psychology of Optimal Experience, by Mihály Csíkszentmihályi, (whose graduate student I used to hang out with during medical school at the University of Chicago, by the way!).

From Wikipedia:

“In positive psychology, flow, also known as the zone, is the mental state of operation in which a person performing an activity is fully immersed in a feeling of energized focus, full involvement, and enjoyment in the process of the activity. In essence, flow is characterized by complete absorption in what one does. Named by Mihály Csíkszentmihályi, the concept has been widely referenced across a variety of fields (and has an especially big recognition in occupational therapy), though the concept has existed for thousands of years under other guises, notably in some Eastern religions.[1] Achieving flow is often colloquially referred to as being in the zone.” (Flow Psychology)

Consider:

immersed

energized

involved

enjoyment

Another adjective that applies when you are in “in the zone” is that you feel “powerful”.

What is the connection between workflow (and workflow technology), in the prosaic sense usually invoked in healthcare and health IT, and feeling powerfully immersed, energized, involved, and full of enjoyment? Workflow is the concept that allows us to understand and design a series of experiences, experiences leading to feelings of powerfulness, instead of powerlessness.

The single most frequent and important reason that workflow fails is that at some step or other a necessary resource is unavailable. If you are poor, or otherwise lack access to necessary resources, your workflows suck and you feel powerless. On the other hand, if, at every step of workflow, all the necessary inputs are present, either due to your bank account or external agency, your workflows don’t suck. And you feel powerful.

How does all of this relate to empowering patients and providers?

Focus on their workflows. Focus on what they are trying to achieve. What steps will achieve it. And what resources each step requires to be a success.

The next horizon in APIs in healthcare are “microservices.” You can think of microservices as the logical continued evolution from software libraries, service-oriented architectures, and APIs (Application Programming Interfaces). APIs have been around for many years. Most EHRs and health IT systems already use APIs in some fashion. Ten years ago as an EHR programmer I “consumed” web APIs, submitting lists of drugs and getting back interactions. I’ve used non-Web APIs since at least the eighties, seventies if you count FORTRAN libraries. Microservices also remind me of RPCs and RMIs (Remote Procedures and Method Invocation) I used in the early nineties. That style of programming faded (tied too tightly to specific platforms) with the advent of the Internet (more interoperable), but now seems (to me) be coming back as microservices, which feel like interoperable remote procedure calls and Java method invocations to me. BTW, I’d love to hear from someone more knowledgable about the similarities and differences among REST, RPCs, RMIs, APIs, and microservices to help sharpen or dissuade my intuition!

On the left, in the above diagram, we have “monolithic applications,” applications made from modules that cannot exist independently from the application. The classic, torn-from-the-headline, example of a monolithic application in healthcare is the electronic health record (EHR). Healthcare is adding APIs to access data inside EHRs. FHIR (Fast Healthcare Interoperability Resources) is best known, but many other non-FHIR APIs and related technologies (such as API creation and management software) are springing into existence, relative to both EHR and non-EHR health IT systems.

All those microservices? Where will they be? Everywhere. Anywhere. It won’t matter. From a task workflow interoperability perspective, process-awareness is, essentially, being virtualized. This fundamental difference from older styles of programming that fail to abstract sufficiently away from health organizational organizational boundaries will be essential for achieving what I call healthcare pragmatic interoperability. Take a look at this series of diagrams from the Jolie (“The first language for Microservices”) website.

How will we get from our current monolithic health information (solar) systems, surrounded by planetary apps, to to a virtual swarm of virtual microservices? The four activities we will see, between now and then, are…

Connecting

Coordinating

Refactoring

Replacing

We need to connect and coordinate an extraordinary variety of apps. And we need to (partially) disconnect and coordinate modules, corresponding to healthcare clinical and management tasks and goals within today’s monolithic applications, especially electronic health records! These monolithic applications will (eventually) be refactored into more independent modules, or be replaced with more modular systems. As disparate apps become connected and coordinated modules, and as monoliths divide into less connected modules, the distinction between modular apps and application modules will gradually disappear.

Lets flash forward to a future in which APIs evolve into microservices. The same forces that drove creating libraries and APIs will also drive creation of micro service architecture.

Does “modular services, each supporting a business goal” sound familiar? It is a step in a business, or often in healthcare, a clinical workflow. We may call them steps, activities, goals, or even experiences. They can even be entire workflows, since one workflow may be merely a step in another workflow. Workflows will be made up of microservices. Some microservices will will drive, and be driven by, user behavior and experience. Some microservices will do stuff behind the scenes, automatically. Some microservices will orchestrate other microservices. Other microservices will interact like jazz musicians or dancers, each following its own set of rules, but working dynamically together to achieve common goals.

“The key system characteristics for microservices are:

Flexibility. A system is able to keep up with the ever-changing business environment and is able to support all modifications that is necessary for an organisation to stay competitive on the market

Modularity. A system is composed of isolated components where each component contributes to the overall system behaviour rather than having a single component that offers full functionality

From libraries and APIs through microservices, software architecture massively influences a wide variety of classic software issues: availability, reliability, maintainability, performance, security, and testability. Every industry — education, telecommunications, finance, healthcare, and so on — is unique in its own way. But at a 30,000 foot level, the evolutionary stages of how we create useful software are the same. Healthcare is just a bit behind some of these other industries. And healthcare APIs are an important step toward catching up with our outside world.

By the way, what’s an “API” and “library”? Here you go. I did’t want to start with these embedded tweets, as that might have interfered with the initial readability of this post. However, if you’ve got this far… 🙂

Let’s continue, in reverse order, through the “Exploring APIs in Healthcare” tweetchat questions.

How are APIs being used to improve patient outcomes?

Technically, since APIs have been around for decades, leveraged by virtually every EHR and health IT system, everything good that health IT has achieved, to improve patient outcomes, has leveraged APIs.

More topical, new FHIR-based apps communicating with EHRs, both mobile and plugged into EHR workflows, are being announced almost weekly. However, I am most interested in non-FHIR-based apps. Why? Take a look at this tweet, from the recent Medical Innovation Summit in Cleveland (my trip report). I am reporting the answer from a panel of FHIR thought leaders in response to the question, what if FHIR doesn’t happen to do what you need it to do?

While I am a fan of FHIR, I am even more a fan of its bringing remote-call API technology into healthcare. Don’t wait for FHIR to deliver bi-directional connectivity and coordination for the data and workflows concerning you. The best of both, of FHIR and non-FHIR, APIs and API technology will lead our way toward sophisticated, orchestrated and choreographed, microservice architectures.

What are the concerns you have about partnering with an API vendor/endpoint?

I know there are many potential concerns regarding APIs, from security to latency to API vendor stability. However, as a programmer, my main concern is API usability. How easy is an API to use? The harder it is to use, the more work it is for me. Remember Dr. Dobbs? It was the original programmer’s programming magazine. In 2004 it published an article titled Measuring API Usability. It wasn’t about RESTful APIs, about which there is so much interest in health IT, but it is still remarkably relevant.

My favorite API usability dimensions are domain correspondence (if you understand the domain, say, clinical documentation, how much will that help you understand the API?), progressive evaluation (how much code do you have to write before you can execute and see if you are on the right track?), and work-step unit (how much work does each API call accomplish). Of the three, domain correspondence is most important to me. It’s a lot like usability in user interfaces, where user knowledge of their domain is enough to guide their interactions with a user interface. If you know anything about workflow technology, in which engines execute models of domain workflow, you can see why these are my favorite dimensions of API usability.

T3: What does a good healthcare API Partner Program include? #AskAvaility

What functionality/capabilities would you like to see in API’s that you’re not seeing? If you haven’t used API’s why not?

The functionalities I am not yet seeing in health IT are workflow APIs. Essentially, we need easy-to-spin-up workflow services, in the cloud, which can be used to coordinate mobile apps and application modules, to combine them into automatic, transparent, flexible, and systematically improvable workflows, within and across healthcare organizational boundaries. Future versions of FHIR may provide API hooks to drive and respond to such cloud-based process-aware workflow engines (see my Health IT Workflow Integration: Whither FHIR? (Fast Healthcare Interoperability Resources). Many modern BPM suites (Business Process Management) already offer APIs into their workflow design and engine guts. This is what I wrote in, Healthcare IT News, in 2015.

“Converse to healthcare interface engines, BPM suites are adding adaptors and plugins and means to manage data flows. Abilities to consume a variety of web services (such as FHIR-based APIs) have been standard functionality for years. A particularly relevant manifestation is data virtualization. Instead of defining workflows directly against a heterogeneous mixture of data systems, the data in harmonized and made visible to the workflows being designed and executed. In turn, some of these systems are exposing not just their internal task, task list, and workflow state, but also this harmonized data. So you can see that healthcare interface engines and business process management suites are, in a sense, heading toward some of the same territory.

Particularly important to task and workflow interoperability is ability of workflow platforms to expose task, task list, workflow state, and related to information, to other applications via APIs (Application Programming Interfaces). If you use a third-party BPM platform (to tie together internal data sources and workflows, as many enterprises are doing), be sure to investigate whether it has both an outward-bound API for exposing data and workflows, as well as an inward-bound API for pushing data and triggering workflows. Workflow management and business process management systems will be key technologies for achieving task and workflow interoperability.

“WFM/BPM systems are often the ’spider in the web’ connecting different technologies. For example, the BPM system invokes applications to execute particular tasks, stores process-related information in a database, and integrates different legacy and web-based systems.” (Business Process Management: A Comprehensive Survey)

The key to success will be integrating data and workflow, through use of both more-or-less traditional healthcare data integration technologies, but also newer workflow management and integration technologies. You need to think about how best to create and evolve a fast, flexible, and transparent backbone of data and workflow services, on which to hang and manage current and future systems.”

Here are a bunch of related tweets. They illustrate lots of connections among workflow concepts and API concepts.

(But don’t forget to get hang in there for, or at least skip to, #AskAvaility topic T1. In addition, my postscript to this already lengthy post, about Jolie (Java Orchestration Language Interpreter Engine), the “first language for microservices”, is not to be missed!)

What are the primary challenges and issues in using API’s within the healthcare industry?

Wow! Am I finally at topic T1! And I am running out of both steam and time. So maybe this is where I need to pivot back to the #AskAvaility tweetchat, where you will surely hear about, and, I hope, suggest API challenges and issues in healthcare. However, I will give you some interesting and relevant links for homework.

I’d love to compare notes with other programmers in the health IT space. Feel free to tweet me at @wareFLO or contact me through this blog.

I’ve been writing microservices in Jolie, “The first language for Microservices.” (Also see Chor, the choreography programming language). Jolie stands for Java Orchestration Language Interpreter Engine and is written in Java. It’s easy to install if you have the most recent Java interpreter running on your Windows, Mac OSX, or Linux computer. (And installing Java is even easier.) I also recommend Atom a free and open source code editor. It highlights Jolie syntax and allows you to conveniently execute Jolie programs. Jolie has lots of documentation and examples. Jolie also has lots of academic papers about it, explaining microservice concepts and how Jolie implements them. Let me know if you delve into Jolie. It feels a lot like Java or C, so if you’ve programmed in them, you’d probably pick it up quickly.

Here is the client code calling microservices. It illustrates three of the four most fundamental workflow patterns. Sequence, parallel split, and join.

Here is the command line output. Text with the plus sign (“+”) is executed “remotely,” which is to say it could just have well executed anywhere else on the Internet.

The above code is not a realistic implementation of the cross-organizational workflow I wrote about in 2005. However, it does illustrate how easy it is to implement concurrency in Jolie, a fundamental function in any workflow platform. Here are some extracts about Jolie from numerous academic papers.

Service oriented computing is an emerging paradigm for programming distributed applications based on services. Services are simple software elements that supply their functionalities by exhibiting their interfaces and that can be invoked by exploiting simple communication primitives. The emerging mechanism exploited in service oriented computing for composing services –in order to provide more complex functionalities– is by means of orchestrators. An orchestrator is able to invoke and coordinate other services by exploiting typical workflow patterns such as parallel composition, sequencing and choices. Examples of orchestration languages are XLANG [5] and WS-BPEL [7]. In this paper we present JOLIE, an interpreter and engine for orchestration programs. The main novelties of JOLIE are that it provides an easy to use development environment (because it supports a more programmer friendly C/Java-like syntax instead of an XML-based syntax) and it is based on a solid mathematical underlying model (developed in previous works of the authors [2,3,4]).”

We extend the Jolie programming language to capture the native modelling of process- aware web information systems, i.e., web information systems based upon the execu- tion of business processes. Our main contribution is to offer a unifying approach for the programming of distributed architectures on the web, which can capture web servers, stateful process execution, and the composition of services via mediation. We discuss applications of this approach through a series of examples that cover, e.g., static content serving, multiparty sessions, and the evolution of web systems. Finally, we present a performance evaluation that includes a comparison of Jolie-based web systems to other frameworks and a measurement of its scalability.”

“Personally I am not a big supporter of REST services, but I think that a technology which aims at being a reference in the area of microservices like Jolie must have some tools for supporting REST services programming. Why? Because REST services are widely adopted and we cannot ignore such a big evidence.

Ideally, Jolie as a language is already well equipped for supporting API programming also using http, but REST approach is so deep coupled with the usage of the HTTP protocol that it introduces some strong limitations in the service programming paradigm. Which ones? The most evident one is that a REST service only exploits four basic operations: GET, POST, PUT and DELETE. The consequence of such a strong limitation on the possible actions is that the resulting programming style must provide expressiveness on data. This is why the idea of resources has been introduced in REST! Since we cannot programming actions we can only program resources.

Ok, let’s go with REST services!

…But,
…here we have a language, Jolie, that is more expressive than REST because the programmer is free to develop all the operations she wants. From a theoretical point of view, in Jolie she can program infinite actions instead of only four!”

Relative to Chor, a choreographic programming language that generates Jolie code, the PhD describing it won the 2014 best dissertation award from European Association for Programming Languages and Systems.

“Chor is still a prototype, and lacks some features that may be useful for integrating its generated code with existing programs. For example, Chor is still limited to simple data structures for messages, such as strings and integers, and does not come with an integrated debugger. We are continuously working for improving Chor with common features needed in production environments, so stay tuned!”

[I wrote this trip report while thinking about today’s #HITsm tweetchat, Top 10 Challenges for Healthcare Executives. In my opinion, the top challenge for healthcare executives is managing innovation. In fact, all five #HITsm topics easily pivot to innovation in healthcare. At the end of this post I’ve (only slightly) rewritten them to emphasize the importance of innovation.]

Imagine combining the 40 best annual HIMSS conference presentations and the 2000 most interesting attendees and speakers. Mix in lots of cool science and conversation about innovation. Then add same night opening games for 2016 NBA Champion Cavaliers (before which they received championship rings) and baseball’s World Series (Indians versus Cubs). Then add robust social media (#MIS2016 on Twitter, over 73 million impressions). You might, might begin to approach the vibe at last week’s 2016 Medical Innovation Summit in Cleveland.

When I was CMIO for an EHR vendor, every time I came back from a conference I’d email around a detailed “trip report”: with whom I spoke, industry trends, specific market intelligent, impressions of demos of competing products, that sort of thing. This trip report is more about local color and vibe. First are ten tweeted photos and a bit of commentary. But there are some “deep thoughts,” to which you are welcome to skip! (Compromise? Slowly scroll though the photos and videos while admiring them?)

OK, a series of tweeted images hardly constitute systematic and incisive analysis of the 2016 Medical Innovation Summit. So I will close with these thoughts.

As I mentioned at the beginning of this post, in the old days my trip reports were detailed and blow-by-blow. Truth-be-told, I not sure how many of my colleagues actually read my entire lengthy emails. So I’ll close with more of rumination on innovation in medical technology and health IT.

The name of the conference was Medical Innovation Summit. A synonym of “innovative” is “creative”. I studied computational models of creativity during my graduate degree in artificial intelligence. Every student of creative starts with Wallas’s four stages of creative thought:

preparation,

incubation,

illumination, and

verification.

The Wallas model has been endlessly elaborated, into five, six and more stages. But I like original model the most. During preparation we immerse ourselves in a topic. We learn everything we can. We turn over every rock, figuratively. Eventually, we run out of rocks to turn over, and then we enter a frustrating phase during which we think nothing is happening. Every creative artist, novelist, and scientist has experienced this funk. However, incubation cannot be rushed. Under the surface, subconsciously connections are being made. Finally, often suddenly, a lightbulb goes on over our head. What actually turns it on can seem like a random environmental cue. This is illumination. But having a bright idea is insufficient. It has be vetted and turned into something useful and sustainable. An actual piece of art or fiction. A successful experiment and then, perhaps, eventually, a disruptive industry technology.

I thought of the Wallas model of creativity during the MIS2016 session, The State of Healthcare Innovation. Someone, perhaps from the audience via the MIS2016 mobile app, asked “Why can we get money out of ATM globally but not share med info?”

Panelists went down the line, addressing this question. Then Carla Smith (EVP, HIMSS) pointed out that the first ATM was installed at the beginning of the seventies. And that it has taken almost a half a century to get to the network of ATMs we take for granted today.

Let’s apply the Wallas model of creativity to an entire industry, AKA innovation in health IT.

I think some current frustration with the state of health IT (you know, with interoperability, usability, safety, patient engagement, and so on) is because we are collectively in the important but frustrating preparation/incubation phase. While progress may seem slow, under the surface, under our collective radar, so to speak, important connections and synapses are forming. At venues such as the Medical Innovation Summit and the HIMSS annual conference, and in between, in startups and hubs and pilots, we see illumination. Bright ideas click “ON” (like those figurative cartoon lightbulbs over our heads), but then must be vetted and designed and deployed.

Umm, I think that’s about as far as I will drive that particular analogy, between a four-stage model of human creativity and health IT innovation… But I would like to point the widely displayed logo slash symbol at the Medical Innovation Summit: a lightbulb!

How will Accountable Care Organization (ACO) IT look in 10 years? How will Actuarial Science fit into that infrastructure? How can workflow technology get us there?

I am not an actuary, but I did get Accountancy and Industrial Engineering degrees (on the way to med school!). In doing so I studied fundamental Actuarial Science concepts: economic risk, random variables, time value of money, and modeling and optimizing stochastic processes (stock and trade for actuaries). Eventually I designed and deployed health IT software. But I’ve kept an interest in financial security systems. From Wikipedia:

“A financial security system finances unknown future obligations. Such a system involves an arrangement between a provider, who agrees to pay the future obligations, often in return for payments from a person or institution who wish to avoid undesirable economic consequences of uncertain future obligations.[1] Financial security systems include insurance products as well as retirement plans and warranties.[2]”

Here are my ten-year “What Will ACO IT” Look Like” predictions:

1. ACO enterprise SW will be ‘process-aware’ (workflow engines executing declarative process models). It will be essential for turning actuarial insight into automated ACO workflows, in almost real-time.

2. Stochastic simulation will literally be built into ACO enterprise software. Simulation is already built into many Business Process Management (BPM) workflow platforms. Actuarial simulation and workflow simulation will increasingly complement and even merge.

3. Virtual ACO enterprises will be built across workflow interoperable healthcare subsystem organizations. For extended discussion of task, workflow, and pragmatic interoperability, see my five-part series

4. ACOs will know exactly how much each service line (chronic Dx, procedure, etc) costs. Comprehensive ACO workflow IT platforms will seamlessly drive sophisticated event-drivenactivity-based cost management systems. Other industries know exactly what their smartphones and vehicles cost. Healthcare needs to do so too.

Relative to intelligent learning systems, I should mention another of my degrees, an MS in Artificial Intelligence. Artificial intelligence, machine learning, workflow technology, business process management, and data pipeline management systems are increasingly leveraging each other’s strengths, and in some cases, even merging. While process-aware workflow technologies will increasingly form virtual ACO IT infrastructure, these workflows will be highly “tunable.” The additional data made possibly by workflow technology about what happened when will increasingly feed into stochastic models, which, in turn, will be essential for systematic improvement of workflows both driven by, and generating the data. This is the “intelligent learning” to which I am specifically referring.

I also have a whole bunch of questions! For example, what, exactly, does “stability” mean? (Probability that premiums will be sufficient to claims cash flows?) What is the current state-of-the-art for actuarial simulation? Are “state models” (as in, Markov models of disease progression) routinely used in ACO actuarial calculations? And so on.

For now, I’ll just close with some thoughts on the intersection among actuarial science, accountable care, and my favorite topics: healthcare workflow and workflow technology!

What is the connection between workflow, workflow technology, actuarial science, and accountable care?

I’ve taken entire courses in workflow. I’ve looked at hundreds of definition of workflow. The following is what I eventually “settled” upon.

“Workflow⁰ is a series¹ of steps², consuming resources³, achieving goals⁴.”

Workflow technology is any technology that represents workflow as a model, explicitly (declaratively) or implicitly (neural network weights), and operates on the model/representation to automatically execute workflows or automatically support human execution of workflows. Academic workflow researchers call these “process-aware information systems.” The best know PAIS are BPM systems. However process-aware workflow tech is rapidly appearing in IT systems, such as Customer Relationship Management systems (CRM) and data and language “pipeline” platforms not typically referred to as BPM systems.

If one modifies my definition of workflow, though within my subscripted limits, to…

Process is a series of events, consuming expected resources, achieving expected benefits

During my student days, we spent a lot of time estimating parameters and distributions, and then predicting behaviors of these stochastic processes. Sometimes we did so analytically with complicated equations (Markov Models). Sometimes we fell back on computer simulation (Monte Carlo).

A quick review of actuarial science literature indicate many of these same techniques are used today. I found questions about them on actuarial science exams and interesting papers by actuarial science researchers. I’ve appended links to some examples at the end of this post.

By the way, I believe my five predictions are incredibly relevant to a very topical topic: MACRA’s “virtual groups.” So I’ll close with this quote (stretches in italic due to me).

“Virtual Groups

“…the MACRA Proposed Rule will likely put pressure on solo practices and small group practices, while favoring large groups.

Fortunately, the MACRA legislation offers a possible “salvation” for solo practitioners in that the rule allows for the formation of “virtual” groups. This would presumably enable smaller practices to band together (virtually) and to function as a larger group, spreading risk and potentially taking advantage of APMs and other benefits the MACRA legislation offers larger practice groups.

Unfortunately, CMS has decided that virtual groups, while mandated by law, were too complicated to set up. Consequently, it is proposing to delay the implementation of virtual groups until 2018.

What is especially ironic about this is that CMS states that virtual groups will be delayed due to the difficulty of establishing an efficient and effective “technical infrastructure” by the beginning of the 2017 performance period. Yet (of course) providers and software vendors are granted no such relief, even though they too will have “technical infrastructure” needs that will have to be enabled in their EHRs in that same restrictive timeframe.

The net result is that without the relief of virtual groups, the majority of small and solo practitioners may be even more unlikely to meet the MIPS standards during 2017, and are more unlikely to avoid penalties being assessed in 2019.”

What’s my point? Well, my predictions are ten years out, and therefore not likely to benefit small medical practices next year. However, I do think the concepts I invoke — virtual ACOs, pragmatic workflow interoperability, true costs, intelligent learning systems — are highly relevant in the long run. Therefore, even when fighting short-term fires, we need to keep our eye on long term goals, and paths to those goals.

Back when I was a CMIO/programmer, we integrated a lot of third-party services with our EHR. In fact, we were constantly contacted by vendors and customers to integrate with this or that partner. We asked two questions of ourselves. Does it serve a need? How easy is it to add to our IT workflows? Clinicians and business people answered the first question. Programmers answered the second.

What’s the best way to see how easy it is to integrate a third-party into your health IT workflows? By taking a quick whack at it. See how far you can get with only a minimum amount of effort. In other words, the proof is in the (eating of the) pudding. It’s the only certain way to tell for sure whether the pudding is tasty, or the integration is (potentially) easy.

Sometimes, over a long weekend, a programmer (sometimes, me) sat down with an SDK (Software Development Kit) just to take a wee keek (as the Scottish say), and showed up Monday morning with a working prototype! This put a very different spin on the first question. Instead of a manager saying, sorry, we already have too many other priorities, they said, how soon can you finish this so we can sell it…

So, this morning I logged into the Availity – Developer Center for Health Care APIs to take a whack at it. I wanted to see how easy and fast it is to pull structured data into this blog post, using PHP (in which WordPress is written). It didn’t take very long at all! At the beginning of this post you saw a subscriber JSON string, a PHP JSON object, and name, gender, birth date, payer, and requesting physician NPI.

By the way, here is some entertaining context! (At least to me…) I attended the AHIP Institute this spring and I did what I (almost) always do. I search every website of every exhibitor for evidence they use workflow technology (workflow/process/orchestration engines, editors, mentions of Business Process Management, and so on). I tweeted I was doing so and then I tweeted what I found.

In the mean time Availity is waving its Twitter hand and tweeting: us, us, us! If you are interested in healthcare workflow, you have just got to come talk to use about our API platform and how it’s used to improve payer/provider workflow. The following is from my post AHIP Institute blog post, AHIP Institute Trip Report: Business Process Management & Workflow Engines.

Availity

The following conversation was interesting because Availity wasn’t actually on my initial list. However, they saw me tweeting about AHIP vendors and workflow and basically demanded I come to their booth. I’m glad I did. As Mark Martin explained, they provide the APIs (and a portal) that can be consumed by workflow tech. In fact, if you think about it, even if you have the best workflow engine in the world, you still need data to achieve whatever strategic goal you set. Availity goes beyond currently, typically available standard APIs to empower necessary administrative workflow between healthcare organizations. I love it. Thank you for your enthusiasm, seeing my #AHIPinstitute tweets, and reaching out about this important topic.